HIV: Interventions to Identify HIV-Positive People Through Partner Notification by Contract Referral Archived Review

The CPST finding is based on evidence from a systematic review (search period 1985 – 2004). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to HIV prevention.

• Number of partners located and notified: 34% and 85% (2 studies)
• There was little difference among the three partner-notification methods evaluated (provider, patient, and contract referral) in terms of the mean number of infected individuals identified (although very few studies tested patient or contract referral).
• Behavioral changes after partner notification:
  • There were changes in the direction of safer sexual behavior with HIV partner notification.
  • Small number of studies and diversity of comparisons and outcomes precludes firm conclusions.
• Data do not suggest substantial harms to the person who is screened and found to be HIV positive resulting from partner notification services (two studies).

An economic review of this intervention was not conducted because CPSTF did not have enough information to determine if the intervention works.

Applicability of this intervention across different settings and populations was not assessed because CPSTF did not have enough information to determine if the intervention works.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for partner counseling and referral services through provider, patient, and contract referral.

Results from the Community Guide reviews of the partner counseling and referral services reviews indicate that a number of PCRS-related issues warrant additional study and evaluation, primarily on patient, contract, and dual referral and comparisons of relative effectiveness among these methods and provider referral.

Approaches to partner notification vary; they include non health-department referral assistance, such as outreach-assisted partner notification; incorporation of social, as well as sexual, networks into PCRS and partner notification; and self-testing algorithms. The last unavoidably delays PCRS compared with in-person counseling and testing (followed by PCRS). Research is ongoing into the effectiveness of these approaches and ways to best match approaches to individuals and communities who are most likely to benefit from them. In trying to compare methods, the field would benefit from further comparisons of provider referral with other referral methods. Among the papers included in this review, the Landis randomized control trial demonstrated a large effect size for provider referral versus contract and patient referral. Nevertheless, comparisons with greater numbers of participants and more diverse settings would improve the quality of comparative evidence. Finally, this review did not specifically address the acceptability of PCRS, including partner notification, to patients and their partners, which should be evaluated further as this may affect the success of the process.

More studies are needed of the effects of PCRS on certain outcomes, especially behavior change and possible harms. The reductions in risk behavior found in Hoxworth subsequent to notification echo the conclusions of a recent meta-analysis showing that risk behaviors among those who know they are HIV-positive are, overall, less frequent than risk behaviors among those unaware of their status. Partner violence, although not proven to be a consequence of notification, is still a putative harm, especially in the context of patient referral (e.g., Rothenberg et al.). Moreover, the existence of violence in relationships where HIV/STD transmission occurs is widely supported anecdotally by public health staff. Even though the nature of the violence and the extent to which observed violence is attributable to notification is unclear, the risk should continue to be recognized by researchers and practitioners.

To the best of our knowledge, the effect on sexual behavior and partner notification participation of laws punishing “knowing transmitters” has not been studied. Research suggests that transmission of HIV may increase temporarily and substantially with STD co-infection, which speaks both to the importance of ongoing HIV partner notification and to the legal implications of admitting to having sex while HIV-positive. (Some jurisdictions have laws against HIV-positive individuals engaging in sex without disclosure of their HIV status. Becoming infected with an STD would constitute proof that the HIV-positive person had had sex, at which point disclosure would become an issue.) This critical contextual variable should receive additional study. Finally, although it seems self-evident that information garnered through PCRS, including partner notification, contributes to our epidemiologic understanding of HIV and its spread, it would be worthwhile to evaluate the benefit of PCRS to the research and programmatic efforts of public health agencies in fighting HIV.

The studies in this review were conducted:

• Among a variety of populations (black and white men and women; gay, bisexual, and straight; intravenous drug users or not)
• In a variety of settings in the United States (statewide in seven states and locally in several cities)
• Over a 20-year period

Effectiveness Review

Analytic Framework – See Figure 2 on page S92

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table
Contains evidence from reviews of partner counseling and referral services through provider, patient, and contract referral

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med 1992;326:101 6.

Spencer NE, Hoffman RE, Raevsky CA, Wolf FC, Vernon TM. Partner notification for human immunodeficiency virus infection in Colorado: results across index case groups and costs. Int J STD AIDS 1993;4:26 32.

The following outlines the search strategy used for the systematic review of partner counseling and referral services through provider, patient, and contract referral.

A comprehensive search strategy for studies evaluating HIV PCRS, including partner notification, was developed in conjunction with HIV reference librarians from the CDC Information Center. The literature search was initiated in September 2003 and later updated in September 2004 using five database-specific search strategies for AIDSLine, Embase, Medline, PsycInfo, and Sociofile. To reduce publication bias and gaps in the automated search, the Community Guide staff conducted additional searches using the Internet, reference lists, and referrals from HIV specialists at CDC and members of the team that conducted the systematic review. Studies were eligible for inclusion if they:

• were published in English during 1985-2004
• were conducted in a country with a high income economy
• assessed partner notification
• provided data to calculate the proportion of individuals tested through partner notification who tested positive for HIV

CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.